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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015601017
Report Date: 08/19/2022
Date Signed: 08/19/2022 09:44:12 AM


Document Has Been Signed on 08/19/2022 09:44 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612



FACILITY NAME:MISSION VILLA RESIDENTIAL CARE HOMEFACILITY NUMBER:
015601017
ADMINISTRATOR:RUBIO, MARISSAFACILITY TYPE:
740
ADDRESS:42423 PASEO PADRE PARKWAYTELEPHONE:
(510) 656-0168
CITY:FREMONTSTATE: CAZIP CODE:
94539
CAPACITY:6CENSUS: 5DATE:
08/19/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Care Staff- Jean BerrisTIME COMPLETED:
09:50 AM
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On today’s date, at 9:00 AM, Licensing Program Analysts (LPAs) L. Fici and C. Lin arrived unannounced to conduct an Annual Infection Control Visit. LPAs was greeted by Care staff- Jean Berris at the front door entrance. Shortly after, Licensee- Marissa Rubio arrived to the facility and met with LPAs.

During the inspection, LPAs toured facility with care staff, including but not limited to front entrance, kitchen, common areas, hand washing stations, bedrooms, bathrooms, and backyard. LPAs observed COVID-19 signage throughout the facility. Hand washing signs were posted at hand washing stations. LPAs observed paper supplies and PPEs are sufficient. Facility has a sufficient 2-day perishable and 7-days perishable food supply. All sharps and toxins were locked up and inaccessible to residents in care. Common areas are disinfected frequently throughout the day. Water temperature is measured at 111.3. Fire extinguisher was last serviced on 7/22/2022. Carbon monoxide and smoke detector are operable. Facility passages inside and out free of obstruction and does not pose a health and safety risk for persons in care.

During record review, LPAs observed facility has a copy of their Infection Control Plan on file.

No deficiencies cited during visit.

Exit interview conducted with licensee and copy of this report provided.
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Liridon FiciTELEPHONE: (510) 359-0768
LICENSING EVALUATOR SIGNATURE:
DATE: 08/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/19/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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